Who is Really Afraid of Death?

She walked down the stairs of our palliative care unit, silent and perturbed. Suddenly, she stopped at seeing me. Her honest eyes said it all. Today she is in stark contrast to her ownself, the one whom I had interviewed last month for senior residency. She had just finished her Masters in Anesthesia and was full of life. But now her life seemed at crossroads. We needed to talk….

She went on logically reasoning what could have been done better. Logics were in place. We discussed it in and out. But her storms refused to calm down. “All through I knew Divya would die. But when it has happened, I feel defeated and helpless. Her relatives’ questions are still haunting me. I feel emotionally drained.” Yes she was.

All through as a medical student, we were preparing her to fight death, the enemy. We never prepared her to face the inevitable truth that death is a part of life. I pondered who really is afraid of death, the patient or us?

Is medical training preparing students to accept the dignity of life as well as the dignity of death? Are we making students logically sound and emotionally enriched also? They should be trained to handle these inevitable moments.

Well-known psychiatrist and thanatologist, Dr. Elizabeth Kubler Ross, had proposed five stages of reactions of patients who have been told of their impending death due to the terminal stage of their illness, such as advanced cancer, although no two persons react the same way and these emotions are not essentially a series (rather can be simultaneous). The following reactions are generally found:

• Shock and denial

• Anger

• Bargaining

• Depression, and finally

• Acceptance.

But what about physicians’ reactions in accepting the death of a patient? Are these reactions an undercurrent in us also…? It might seem easy to avoid death and dying, but escapism would leave us emotionally cold, conflicted, and stressed. Focus on cure should not be at the expense of reluctance of diagnosing death.

The study of life would be incomplete without the study of death. We need to include workshops on the principles of Thanatology and communication to make medical training holistic. Thanatology studies the dying process, the grieving process, and the social attitudes toward death, including rituals and memorialization. It would prepare medical professionals to elevate the lives of people they come across in their professional journey. It would also leave us in process enriched as we accept death as an essential friend of all life forms, not a foe.

Various research support groups are of the view that open communication in the dying phase can contribute to the quality of the dying process. Being aware of dying was found to correlate with acceptance of dying. But the prerequisite I believe is physician's acceptance that patient is dying. It should be an active acceptance. Though some may argue that shattering patient's hope for recovery could take a severe emotional toll and may be eventually fatal. In a way, this escapism is self-justified as prolonging the patient's life. But good health was a routine the patient was living with for years. All denials aside, patient has a sense that things are not the same. Our reluctance to accept and communicate truth would be at the cost of mutual trust. Obviously, it should be communicated in a stepwise and humane manner. It would also help the patient in crucial decision making, which can affect the lives of their near and dear ones. This is also concluded in various studies that accepting imminence of death can help resetting of goals by health care professionals and lesser diagnostic procedures. Patients who were aware of imminence of death were more often in peace with dying and felt more often that life had been worth living.

According to Hindu mythology, Lord Shiva abides on both Mount Kailash and in Smashana. Kailash means “where there is only celebration” and Smashana is the cremation ground – “where there is only void.” Divinity dwells in the void as well as celebration. Because in us there is void, in us there is celebration.